odgers heme/immunodefi

HGB<12G/DL FEMALE, <14 G/DL MALE

DECREASED RBC PRODUCTION

INCREASED RBC DESTRUCTION

BLOOD LOSS

CAUSE IS ALWAYS AN UNDERLYING.

PROTEIN MOLECULE IN RBC THAT CARRIES OXYGEN

THE PROPORTION OF BLOOD THAT CONSISTS OF RBCS.MEASURED AS VOLUME

OXYGEN ENTERS RBC AND ATTACHES/BINDS TO IRON FE

MEAN CORPUSCULAR HEMOGLOBIN AMOUNT OF HGB IN RBC 27-34 PG

27-34 PG

HYPOCHROMIC ( LOW MCH)

NORMOCHROMIC ( NORMAL MCH)

HYPERCHROMIC (HIGH MCH)

MEAN CORPUSCULAR VOLUME

MEASURES SIZE OF AVERAGE RBC

CATEGORIZING ANEMIA

MICROCYTIC -<80 FL

NORMOCYTIC -NORMAL MEASURE 80-100 FL

MACROCYTIC >100FL

IRON DEFICIENCY

THALASSEMIA

ANEMIA OF CHRONIC DISEASE (acd) OCCASIONALLY

ACUTE BLOOD LOSS

ACD INCLUDING RENAL FAILURE'

HEMOLYTIC

MEGALOBLASTIC ANEMIA

B12 OR FOLATE DEFICIENCY

RED CELL DISTRIBUTION WIDTH

MEASURES VARIABILITY OF RBC SIZE

NORMAL =HOMOGENOUS RBC SIZE

CAN BE NORMAL IN FOLLOWING ANEMIAS:

ACD, ETOH, RENAL INSUFFICIENCY, LIVER DISEASE

INCREASED =HETEROGENOUS (VARIED) RBC

IDA IRON DEF ANEMIA (11.5-15)

MCH<

MCV<

RDW= OR >

SE FERRITIN <

SE IRON <

TIBC/SERUM TRANSFERRIN >

TSAT RATIO <

SYMPTOMATIC W HGB <6G/DL, CAN BE AT <11 G/DL

MILD- FATIGUE, MILD DYSPNEA, MILD EXERCISE INTOLERANCE

MODERATE- SEVERE- TACHYCARDIA, MARKED DYSPNEA, ACTIVITY INTOLERANCE, PALLOR

ELDERLY - EXCACERBATION OF COMORBIDITIES - DEMENTIA, HF ,CHEST PAIN

MOST COMMON CAUSE OF ANEMIA

MOST COMMON NUTRITIONAL DEFICIENCY

CHRONIC BLOOD LOSS FROM

MENORRHAGIA

GIB

PREGNANCY

LESS COMMON CAUSES

DIET

MALABSORPTION-CELIAC, H PYLORI, GASTRIC BYPASS

EXTREME ATHLETES

THALASSEMIA

NON ANEMIA

HYPOTHYROID

PREGNANCY

UTERINE FIBROID-STUPID

BETA/ALPHA

GENETIC DISORDER

NORMAL BETA/ALPHA RATIO DISRUPTED 2/2 VARIANT IN ONE OR MORE GLOBIN GENES

POPULATION:

AFRICA ( BETA) ASIA MEDITERRRANEAN

TYPES : GENOTYPE -ALPHA OR BETA

PHENOTYPE: MINOR, INTERMEDIA OR MAJOR

LAB TEST :

HGB ELECTROPHERESIS

FERRITIN -EARLIEST LAB ABNORMALITY can stand as alone lab

IRON STORES

MOST ACCURATE TEST TO DX IDA

NORMAL VALUES

WOMEN 12-150 NG

MEN 15-300

DECREASED FERRITIN = IDA

INCREASED FERRITIN = ACD, SIDEROBLASTIC ANEMIA

CHRONIC INFLAMMATION STATES: 50 NG IS CONSIDERED IDA

EG ?CROHNS

SERUM IRON -THIS IS CIRCULATING IRON

< IDA

TIBC-TOTAL IRON BINDING CAPACITY

SERUM TRANSFERRIN

>IDA

TSAT- TRANSFERRIN SATURATION

RATIO BETWEEN SERUM IRON AND TIBC

<IDA

PERIPHERAL BLOOD SMEAR

RETICULOCYTE COUNT -BABY RBC <

BONE MARROW

STOOL OB

HCG TEST (PREGNANCY)

ida can give false + high hgb aic

TYPE OF ANEMIA IDA b12/folate ACD

HGB LO LOW OR NORMAL LO

MCV LO HIGH NORMAL

MCH LO/NORM NORMAL

FERRITIN LO NORMAL OR HI NORMAL /HI

SERUM IR LO ? LO

TIBC HI NORMAL LO/NORMAL

TSAT LO ? HIGH

IRON SUPPLEMENT ORAL 150 dailiy

FESO4 325 TID -65MG

FE FUMARATE 325 106

FE GLUCONATE 325-36

BIOAVAILABLITY < FOOD AND CALCIUM PRODUCTS

> OJ ASCORBIC ACID

IV IF SEVERE OR CANNOT TOLERATE ORAL

IDENTIFY CAUSE REFER

GI - + GUAIAC OR FIT

GYN-MENORRHAGIA

4 WEEKS

REPEAT CBC AND FERRITIN, '

RETICULOCYE COUNT INCREASES IN 5 DAYS

FERRITIN -4-6 MONTHS TO REPLENISH

CONTINUE SUPPLIEMENT FOR 3 M ONTHS AFTER CBC NORMALISES

CBC MONITOR PERIODICALLY

REFER FOR UNDERLYING- ALL MEN AND MENOPAUSAL WOMEN TO GI

REFER TO HEMATOLOGY IF NO IMPROVEMENT IN 1 MONTH

PERNICIOUS ANEMIA MOST COMMON, ABSENCE OF INTRINSIC FACTOR

INADEQUATE DIET- VEGETARIANS -NO EGG MILK POULTRY MEAT

MALABSORPTION - SPRUE,POST GASTRECTOMY, ILEOSTOMY

MEDS> PPI, H2 RECEPTOR BLOCKERS, METFORMIN

TAKES ABOUT 10 YEARRS TO DEVELOP

ETOH

MALABSORPTION -CELIAC SPRUE

DECREASED DIETARY INTAKE

PREGNANCY

VIT B12

USUALLY MILD AND INCIDENTAL FINDING

SYMPTOMS -LOOK TO THE MOUTH!

SMOOTH RED SHINY TONGUE,

SORE MOUTH,

TASTE LOSS

NEURO SYMPTOMS

< VIBRATORY SENSE,

< PROPRIOCEPTION

PERIPHERAL NEUROPATHY

ATAXIA

LATER: SPASTICITY, + ROMBERGS SIGN, HYPERREACTIVE REFLEXES

SOMETIMES PERMANENT DEFICITS IF >6 MONTHS

FOLIC ACID

NO NEURO SYMTOMS

VIT B12 LEVEL <300NG/ML

FOLATE <3 NG/DL. RBC FOLATE <150 MG/ML

CAN OCCUR TOGETHER

> HOMOCYSTEINE LEVEL -BI12 + FOLATE

METHYLMALONIC ACID (MMA) INCREASED WITH B12 DEFICIENCY,NORMAL W FOLATE DEF- USE THIS TEST TO CONFIRM B12 DEFICIENCY

IF B12 CAUSE :

CHECK FOR PERNICIOUS ANEMIA ANTI if ANTIBODIES OR SCHILLING TEST

PERNICIOUS ANEMIA

B12 DEFICIENCY CAUSED BY AUTOANTIBODIES THAT INTERFERE WITH INTRINSIC FACTOS, GASTRIC PARIETAL CELLS OR BOTH.

PATHO: INTRINSIC FACTOR FROM GASTRIC PARIETAL CELLS IS REQUIRED FOR VIT B12 DELIVERY TO THE SMALL INTESTINE ( TERMINAL ILEUM-B12 ABSORBED)

WBC DECREASED,

HYPER SEGMENTED NEUTROPHILS

PLATELETS DECREASED

HEMOLYTIC PROFILE:

>INDIRECT ( UNCONJUGATED?) BILIRUBIN

>LACTATE DEHYDROGENASE (LDH)

VIT B12 MONTHLY IM

1000 MCG DAILY X 1 WEEK

THEN WEEKLY X 1 MONTH

THEN MONTHLY

ORAL VIT B12 1-2 MG DAY

NASAL VIT B12 -CALOMIST 25 MCG-1 -2 SPRAY EACH NARE DAILY

LIFETIME THERAPY

FOLIC ACID 0.4 MG 1 TAB DAILY PO

FOLTX 1-2 TABS DAILY

FOLMOR 1-2 TABS DAILY

USU TREAT FOR 1-4 MONTHS

EDUCATE RE LIFELONG TREATMENT

DIET:

FISH, MEATS, PEAS, BEANS-PROTEIN RICH

FORTIFIED CEREALS AND SUPPLEMENTS

RECOMMEND DIETARY INTAKE: 400 MCG OF FOLATE DAILY ‘FOOD SHIGH IN FOLIC ACID:

GREEN LEAFY

MEAT FROM ANIMAL SOURCES

COMMON IN PATIENTS WITH CHRONIC INFECTIOUS, INFLAMMATORY AND MALIGNANT DISEASES

MCV/MCH -NORMAL

FERRITIN-NORMAL OR HIGH

SERUM IRON -LOW

TIBC-LOW

TSAT- HIGH

MCV 80-100 FL

ACUTE BLOOD LOSS

ACD INCL RENAL

HEMOLYTIC

ACUTE BLOOD LOSS?

HEMOLYTIC INCREASED RBC DESTRUCTION

LDH>

INDIRECT BILIRUBIN >

RECTICULOCYTIC COUNT >

HEMOGLOBIN -HAPTOGLOBIN < REFER

COOMBS TEST+ IF AUTOIMMUNE HEMOLYTIC ANEMIA, IF RETIC COUNT ELEVATED

? SICLKLE CELL-

SICKLEDEX TEST

PERIPHERAL BLOOD SMEAR

HGB ELECTROPHERESIS

DECREASED RBC PRODUCTION

NUTRITIONAL CAN BE NORMOCYTIC-

FERRITIN

HOMOCYSTEINE

RENAL INSUFFICOENCY - CREATININE

CHRONIC ILLNESS? GET GOOD HISTORY

MCV/MCH N

FERRITIN >

SERUM IRON<

TIBC <

TSAT >

CRP AND ESR ARE INFLAMMATORY MARKERS

FERRITIN IS MAJOR IRON STORAGE PROTEIN AND REFLECTS TOTAL BODY IRON STORES AND RESERVES

REMEMBER * FERRITIN IS REACTANT AND CAN BE ELEVATED DUE TO INFLAMMATION-FERRITIN RELEASED FROM TISSUES /LIVER THAT ARE DAMAGED BY INFLAMMATION

IRON

SERUM IRON REFLECTS THE AMOUNT OF IRON BOUND TO TRANSFERRIN

TRANSFERRIN IS A CARRIER PROTEIN THAT REGULATES IRON TRANSPORT IN THE BLOOD

TRANSFERRIN IS MEASURED INDIRECTLY BY THE TIBC

TIBC INDICATES THE AVAILABILITY OF BINDING SITES ON THE PROTEIN FOR IRON TRANSPORT

NCREASED:

BACTERIAL INFECTION

MEDS: STEROIDS

LABA AND SABA

LITHIUM can cause dm

EPINEPHRINE

EMOTIONAL STRESS

CHRONIC INFLAMMATION

HEREDITARY

DECREASED:

FOLATE/B12

CHEMO

Leukocyte refers to any type of WBC, including neutrophils, eosinophils, basophils, monocytes, and lymphocytes

Leukocytosis refers to elevated WBC (leukocyte) count. Neutrophilia is the most common type of leukocytosis, but leukocytosis may also be due to increased monocytes, eosinophils, basophils, and/or lymphocytes.

Left shift is an ill-defined term that refers to an increase in the percentage of band forms, generally accompanied by metamyelocytes and myelocytes.

Leukemoid reaction refers to WBC >50,000/microL from causes other than leukemia, with the majority being mature neutrophils, often accompanied by increased numbers of bands, metamyelocytes, and/or myelocytes

INCREASED:

VIRAL INFECTIONS mono!

LEUKEMIA

LYMPHOMA

DECREASED IN HIV,VIRAL INFECTIONS POOR NUTRITION AND OTHER REASONS

T CELLS -THYMUS

B CELLS -ANTIBODIES

INCREASED:

EBV -MONONUCLEOSIS

FUNGAL

PROTOZOAL

TB

AUTOIMMUNE

SPLENECTOMY

IF MONO ELEVATED >24 HOURS = CHRONIC INFECTION

( MACROPHAGES ARE LARGEST CELLS)

ALLERGIC

PARASITIC

ALLERGIC

INFLAMMATORY

CML

OCP -ORAL CONTRACEPTIVE PILL!!

IMMATURE NEUTROPHILS

“SHIFT TO THE LEFT”

white blood cell (WBC) count >25,000/microL. SUSPECT ACUTE INFECTION

Leukocyte refers to any type of WBC, including neutrophils, eosinophils, basophils, monocytes, and lymphocytes. The various types of leukocytes are discussed separately. (See "Evaluation of the peripheral blood smear", section on 'White blood cells'.)

●Leukocytosis refers to elevated WBC (leukocyte) count. Neutrophilia is the most common type of leukocytosis, but leukocytosis may also be due to increased monocytes, eosinophils, basophils, and/or lymphocytes.

Left shift is an ill-defined term that refers to an increase in the percentage of band forms, generally accompanied by metamyelocytes and myelocytes.

Certain bacteria (eg, pneumococcus, staphylococcus, clostridial species) may cause particularly high leukocyte counts.

STRESS AND OBESITY ALONE CAN CAUSE LEUCOCYTOSIS

CIGARETTE SMOKING CAUSES IT

FEVER

ANTERIOR CERVICAL LYMPH NODES ENLARGED AND TENDER

PHARYNX -EDEMA ERYTHEMA

PALATE -PETECHIAE

NO RASH ( THATS STREP)

CBC W DIFF

WBC ELEVATED

LYMPHOCYTOSISLYMPHS 20%

MONOSPOT+VE BY WEEK 2-3 /heterophil

EBV ANTIBODY TITERS

ANTI VCA IGG AND IGM

ANTI EA IGG AND IGM

EBV NUCLEAR ANTIGE(EBNA)

STREP TEST

LF tWILL BE ELEVATED

ABD USS

SPLENOMEGALY AND HEPATOMEGALY

RECUPERATE

SCHOOL/WORK GUIDED BY SX

NO CONTACT SPORTS FOR 3 WEEKS -SPLEEN RUPTURE

PHARM

TYLENOL

NO ANTIVIRALS

NO ABX

AVOID STEROIDS-UNLESS PHARYNGEAL SWELLING

1-2 WEEKS DEPENDENT ON SEVERITY

FEVER -95%

WEAKNESS -85

HEADACHE 75%

RHINITIS 65%

SORE THROAT 55%

NOW 4 PLEX RSV FLU A FLU B COVID

NAAt OR RAPID MOLECULAR ASSAY

DROPLET SURFACE

CONTAGIOUS 1 DAY BEFORE AND 5-7 DAYS AFTR SX

INCUBATION 2 DAYS

MOST FLU IN FEB

FLU A SUBTYPES H1N1

KIDS UNDER 2 ADULT >65

IMUNE

CARDIO, RESP, NEURODEVE,. DM HEPATIC , ASTHMA , EVERY SYSTEM

PREGANT + POST PARTUM

YOUNG ON LONG TERM SALICYLATES (?UC)

OBESE

INSTITUTIONALIZED

TAMIFLU OSELTAMIVIR

75 MG BID X 5 DAYS renally excreted

CHEMO PROPHY

75 MG OD X 10 DAYS

INHALED XANAMIVIR CAN CAUSE BRONCHOSPASM